Erectile dysfunction (impotence)

The outlook for men with erectile dysfunction (ED) has improved
enormously in the first 14 years of this century – so much so that almost all
patients nowadays can be assured of a return to fairly successful
intercourse.

Further treatments continue to be developed, and an ingenious
new one was released in 2014.

Many males feel that the new treatments for erection difficulty
(formerly known as 'impotence' or 'impotency') have transformed their
lives.

What is erectile dysfunction?

First, let's define the problem. ED means an inability to get a
good enough erection to achieve satisfactory intercourse.

Some sufferers can't get a 'hard-on' at all. Others get one, but
it isn't firm enough to penetrate the partner. And others can manage
penetration for a bit, but then they lose it.

Why does ED occur?

ED is very common, and it occurs for a variety of reasons and at
different ages.

Teenagers and young men

In younger males, the most frequent cause is
anxiety –
particularly nervousness about having sex, about causing a pregnancy or about
using a
condom.

A lot of men in this age group complain that they 'can't get
on with a condom' because as soon as they try to put it on, they lose their
'stiffy'. We have termed this 'condom collapse syndrome'.

Middle age

Common causes in this age group are overwork,
stress, guilt and
bereavement (ED often
happens when a widowed man tries to form a new sexual relationship). A few
cases are due to
diabetes.
Alcohol,
nicotine and other
drugs can be factors, as can
obesity. So if you’re
overweight, it’s worth slimming down.

Post-middle age

In this group of men, ED gets commoner with increasing age.
Nonetheless, 70 per cent of all 70-year-olds are sexually potent.

It is now clear that in a high proportion of cases, the
problem is due to narrowing of the blood vessels that carry blood into the
penis.

Recent research,suggests that in some older men who have
erection difficulties, there may also be deterioration in the arteries of the
brain or the heart.

Leading British sex expert Dr Geoffrey Hackett has repeatedly
warned, 'Erectile dysfunction is the manifestation of vascular disease in
smaller arteries and can give a two to three year early warning of
heart attack.'

This doesn't mean that if you have erection problems, you're
about to have either a
stroke or a heart
problem.

But older men with ED should take care to protect themselves
against strokes and heart attacks – for example by keeping their
blood pressure and
cholesterol down and
getting an adequate amount of exercise. Also, at all costs they should avoid
smoking.

You may be surprised to see that I have not listed 'lack of
hormones' as a common cause of ED. In fact, lack of male hormone is quite rare.
However, it can occur particularly after severe injuries to the testicles or to
the base of the brain.

If you are tempted to go to one of the private clinics that make
a habit of diagnosing 'male hormone deficiency', and then charging huge sums of
money for testosterone treatment, I suggest you think twice.

Nevertheless, if you are a middle-aged or elderly guy who has
erectile problems, it may be worth having a blood test to check your serum
testosterone level. If it turns out to be low, then a course of testosterone
pills could help you.

What is an erection?

An erection occurs when blood is pumped into the penis and stays
there, making it hard. It generally happens because a guy is thinking about sex
or because his penis is being stimulated – or both.

The result is that signals go down the nerves that lead from his
spinal cord to his genitals. They tell the blood vessels which supply the penis
to open up. Blood flows in and the organ 'blows up' like a balloon. A valve
mechanism near the base of the penis keeps the blood from flowing out again – a
least, until sex is over.

As you can see,
getting an erection
is a complex process. It's awfully easy for various factors to interfere with
it – for instance, worry, tiredness, too much alcohol or in later life,
narrowing of the blood vessels.

Nicotine is now known to narrow those vital blood vessels –
which is why ED is much commoner in smokers. But often, there is nothing
physically wrong with men who develop ED.

Are many cases due to psychological causes?

Yes, particularly in the young. In general, erectile dysfunction
is quite likely to be psychological rather than physical if the man:

What treatments are now available?

Personally, I feel that in some cases of psychologically-induced
ED, it's worth trying erection-aiding drugs to help 'kick-start' the man back
into action and boost his confidence. Not all doctors agree with
me.

The treatments for the type of ED that has a physical origin are
listed below.

Erection-aiding drugs

Oral drugs, which help produce an erection in response to sexual
stimulation, have revolutionised the treatment of ED over the last 17 years,
since 1997.

They don't work for everybody, but they ‘do the trick’ for the
great majority – even in diabetes. They can also sometimes help people with
neurological and spinal problems.

Also, the choice of available drugs means that if one particular
drug doesn’t suit you, it's well worth trying one of the others.

There are now four orally-administered drugs available in the
UK. They all have side-effects, only a few of which we can list here. For more
information, read the package insert leaflet, and if in doubt ask your
doctor.

For a small number of men, it's not safe to use these drugs.
Also, some medications interact dangerously with them.

Therefore, before going on any of these pills you should always
see a doctor, talk things over with him or her, and have a physical check-up.

Do not buy erection drugs by mail-order or from chaps you meet
in pubs! They may not be the right thing. In fact, there have been several
recent cases of cruel scams, in which men were sold fake Viagra.

Spedra or Stendra
(avanafil) – now (July 2014) prescribable privately in Britain, but at
present you might have difficulty in getting it from a GP.

Viagra (sildenafil)

It widens the bloods vessels, so giving an erection – provided
there is some sexual stimulation – such as rubbing.

In most men, it works within an hour. The effect lasts for
about four hours. (This doesn't mean the erection lasts for four hours, rather
that an erection can be produced for up to four hours after taking a tablet.)
It's easily blocked by food in the stomach.

Viagra still remains the world's most popular ED drug.

At the Vienna International Sexology conference of December
2006, which we attended, it was claimed by American doctors that its continuing
popularity is due to the 'hardness' of the erections it produces.

And it certainly does give you excellent stiffness. However,
we're not convinced that it produces greater hardness than the other
drugs.

The most common side-effects are
headache, visual
disturbances, blocked nose, flushed face, indigestion, palpitations – and
dizziness after getting out of bed too quickly. Blue vision occurs at higher
doses, but it only lasts a short time.

Viagra is dangerous with certain heart drugs. It interacts
with many medications. Do not drink grapefruit juice on the day of use, because
that pushes up the blood level of the drug.

In 2005, a report from the University of Minnesota revealed ed
that a small group of men have suffered blindness as a result of Viagra use. It
was claimed that the drug may rarely cause a serious eye condition called
non-arteritic ischaemic optic neuropathy (NAION).

It's now apparent that a very small number of British men have
suffered similar eye problems. If you are taking Viagra, you should ask your
doctor to keep you informed of any further research on this development.

Also, in 2007 concerns began to emerge about whether Viagra
could cause deafness. In that year, the American Food & Drug Administration
(FDA) told manufacturers of all three ED medicines to mention this possibility
more prominently on their leaflets for patients.

And in 2011, a well-argued study published in the respected
British journal 'The Laryngoscope' showed that sudden deafness does indeed seem
to occur occasionally in men who have recently taken Viagra or one of the other
two medicines.

Admittedly, only eight cases had been recorded in the UK. But
there were 240 possible cases in America.

This type of deafness is called sudden sensorineural hearing
loss (SSHL).

It generally affects only one ear and mostly seems to happen
within 24 hours of taking Viagra or one of the other ED medicines.

As yet, no one has proved that this deafness is definitely due
to Viagra, Cialis or Levitra. But if you suddenly lose your hearing after using
one of these drugs, do NOT take any more until you have consulted an ear, nose
and throat specialist.

Cialis (tadalafil)

Works in the same way as Viagra. Now popular with a lot of
men, because its effects last so long – at least 12 hours in most cases, which
means sex can be more spontaneous. Manufacturers claim it is not blocked by
food.

Side-effects are similar to those of Viagra, but it can also
cause
back pain and muscle
pain.

Interactions with other drugs and with grapefruit juice are
similar to those of Viagra but also Cialis clashes with the antibiotic
clarithromycin and
the sedative
phenobarbital.

Cialis is very similar in structure to Viagra and there have
been several reports of blindness occurring while on it. Also, it may be a
cause of sudden deafness (please see above).

Levitra (vardenafil)

Works in the same way. Side-effects and interactions are
similar to those of Viagra and Cialis. Not as long-lasting as Cialis. There
have been a very few reports of blindness and deafness (see above).

Please note the alleged relationship between these three drugs
and blindness or deafness is still the subject of argument – and litigation. A
'cause and effect' has still not been proved.

The above three drugs are supposed to be 'prescription-only' in
the UK and most other countries.

However, in 2012
Lloyds and other large British high street chemists
are offering a service through which a man can obtain Viagra directly from a
pharmacy after undergoing some basic tests and filling in a health
questionnaire. There's a back-up from online doctors, but you do not usually
meet them face-to-face.

Also, it is now very easy to buy Viagra, Cialis and Levitra
through the internet, but I really do NOT recommend this – particularly because
criminals have been making a fortune by selling fake tablets on the
net.

There is another oral anti-ED drug called 'Uprima', but it was
withdrawn from sale in Britain during 2006 – probably for commercial reasons.
It's now almost impossible to obtain it.

Spedra or Stendra (avanafil)

Introduced in early 2014,
avanafil belongs to
the same chemical group as the other three oral drugs. But the big advantage
being claimed for it is that it works fast.

The manufacturers say that it is absorbed so rapidly that most
men can get an erection within 15 minutes of swallowing the tablets.

Avanafil has broadly similar side-effects to those of the other
three drugs. And it interacts with many other medications, in much the same
way. So please read the leaflet that should come in the packet.

At the moment, avanafil has just become available for UK doctors
to prescribe privately, but it’s unlikely that your GP will be familiar with
it.

Getting it free on the NHS is improbable, unless you have one of
a short list of officially laid-down medical conditions.

However, it is very easy to obtain via the internet – at about
£4 per 100mg tablet.

Nevertheless, I strongly recommend that you consult a doctor
before starting to use it. (It would be unwise to buy anything described as
‘generic Spedra’ via the web, since the drug is legally under patent in the
UK.)

Availability

Viagra, Cialis, Levitra and Spedra are supposed to be
'prescription-only' in the UK and most other countries. However, large British
high street chemists are now offering a service through which a man can obtain
Viagra or the others directly from a pharmacy after undergoing some basic tests
and filling in a health questionnaire.

There's a back-up from online doctors, but you do not usually
meet them face-to-face. Also, it is now very easy to buy Viagra, Cialis and
Levitra through the internet, but I really do not recommend this – particularly
because criminals have been making a fortune by selling fake tablets on the
net.

There is another oral (and very different) anti-ED drug called
'Uprima', but it was withdrawn from sale in Britain during 2006 – probably for
commercial reasons. It's now almost impossible to obtain it in the
UK.

What other drug treatments for ED are there?

It's also possible to give erection-inducing agents
by:

injections into the penis, usually involving the drug
alprostadil
(Caverject), which widens the blood vessels and so promotes erection

These methods have become less popular since the increasing
availability of oral drugs, but they suit a small minority of men. You have to
be quite brave to give yourself a jab in the penis. For details of
side-effects, consult your GP.

The new erection cream

In 2014 at the European Society of Contraception meeting in
Lisbon, there was an impressive presentation of a new ‘erection cream’. In
fact, it has been under trial in various forms, in China and elsewhere, for
over 10 years.

This cream actually contains alprostadil – which is the same
drug contained in Caverject and Muse (see above). But the idea with the cream
is that you just put it into the tip of your penis. With luck, you get an
erection shortly afterwards.

The cream has just (2014) reached Britain, under the brand-name
of
Vitaros. This
product comes in little single-dose containers, each of which is fitted with a
plunger. You press the plunger in order to squeeze the cream into the opening
at the end of your penis.

Success rates with Vitaros are certainly not 100 per cent. In
one trial which we found, 40 per cent of men reported good erections – but
other studies have given better results.

Possible side-effects include burning, redness and even pain in
the penis. For full details, please consult the package leaflet.

Effect on Women: it’s important to realise that
a man who uses alprostadil on his penis will inevitably transfer the drug to
the delicate mucous membranes of his sexual partner.

So women are liable to feel burning and stinging in the vaginal
area.

Therefore, I strongly recommend that if you are a man who wants
to try this cream, you should always wear a condom – throughout vaginal, oral
or any other kind of sex.

What mechanical aids are there for ED?

There are a number of devices that can help men to achieve a
better erection and to have successful sex.

Vacuum pumps

A pump is a cylinder that you put over your penis. You then
pump out the air. That should 'suck' your penis into an erection – which,
however, tends to be a bit cold and (in fair-skinned men)
blue-looking.

Quite a lot of men do use vacuum pumps, as shown by the fact
that there are currently no less than 11 different vacuum devices available for
prescription by doctors.

However, as is the case with other treatments for erectile
dysfunction, you can only obtain them free on the NHS from your GP if you have
one of a short list of physical disorders, which were specified by the then
Minister of Health back in 1999. Health back in 1999. The commonest of these
disorders is diabetes and the others include
multiple sclerosis,
Parkinsonism and
spinal cord injury.

If you don't have one of those disorders, the cost of buying a
vacuum cylinder is generally in excess of £100.

Rings

Specially-designed rings that fit round the base of the male
organ are often used with vacuum pumps. However, they can be tried on their
own. The idea is that the ring helps stop the blood from flowing out of the
penis.

Again, your GP can prescribe these rings, but you would only
get them free if you have one of the disorders on the above-mentioned NHS list.
Otherwise, the current cost of penile rings is between £10 and £40.

External splints

These are supposed to prop the penis up during sex. Not
awfully successful, in my view.

Vibrators

Although vibrators aren't often prescribed by doctors (and
certainly not on the NHS), I have found that they can be quite useful in urging
a lethargic penis into life.

Some vibrating devices, such as the Penisator, actually clip
round the male organ.

In December 2006, at the Vienna conference, it was reported
that vibrators are surprisingly effective in helping men with spinal injuries
to achieve an orgasm – and therefore to have children.

What about surgery?

In the 1990s, there was great hope that surgery would cure a lot
of men who had ED.

Unfortunately, it hasn't worked out like that, and it's rare to
see a man whose erection problems have been put right by a surgical
operation.

The types of surgery which are available for ED are as
follows.

Curing a vein leak. As we've indicated above, a very few men
lose their erections because blood leaks out of the penis through a leakage in
the veins. Occasionally, this leak only occurs in certain sex positions. Where
a leak can be clearly pin-pointed by special
X-rays, a urologist
may be able to operate in order to improve matters.

Insertion of internal splints. A skilled urologist can insert
artificial splints inside the body of the penis. With the simplest type of
splint (which is just a firm rod), the man lifts the organ into a vertical
position when he wants to have intercourse. There are more sophisticated (and
much more expensive) internal splints that you or your partner can inflate when
you wish to make love. Some couples report being very pleased with these. But
if anything goes wrong with the surgery – for instance, infection or bleeding –
you could be in some trouble.

Summing up

Erectile dysfunction is usually treatable these days. However,
it's important to first establish what the cause is.

Very often, there are several causes, including both physical
and psychological factors.

Commonsense measures will often help – for instance, cutting
down on overwork, stress,
alcohol or smoking, getting more sleep
or stopping any medications which interfere with erection. Your GP should
assist you in these areas.

If he can't, then talk to one of the organisations listed below.

Further help

The following can sometimes be helpful in various ways to ED
sufferers and their partners.

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